Category Archives: Underwriting

Medical underwriting and risk adjustment practices: New Zealand

Health insurance models vary from country to country. As highlighted in our first series of articles on international health markets, governments often dictate the role of private and public health insurance within any country. Milliman has produced a new series of blogs focused on the medical underwriting and risk adjustment practices of eight countries: Australia, Ghana, Ireland, New Zealand, Saudi Arabia, South Africa, Spain, and United Arab Emirates. This is the fourth article in our series.

The publicly funded health system in New Zealand is a tax-funded system that provides (largely) free healthcare at the point of use to New Zealand permanent residents and citizens, plus various other eligible groups.

The Ministry of Health allocates more than three-quarters of the $14 billion of public funds it manages through government health funding to 20 regional district health boards (DHBs). DHBs use this funding to plan, purchase, and provide health services within their areas, including primary care, hospital services, public health services, aged care services, and services provided by other nongovernment health providers including Māori and Pacific providers.

Most of the remaining public funding provided to the ministry is used to fund national services such as disability support, public health, specific screening programs, mental health, elective services, well child and primary maternity services, Maori health, and postgraduate clinical education and training.

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Medical underwriting and risk adjustment practices: Ghana

Health insurance models vary from country to country. As highlighted in our first series of articles on international health markets, governments often dictate the role of private and public health insurance within any country. Milliman has produced a new series of blogs focused on the medical underwriting and risk adjustment practices of eight countries: Australia, Ghana, Ireland, New Zealand, Saudi Arabia, South Africa, Spain, and United Arab Emirates. This is the third article in our series.

Ghana reformed its healthcare provision and launched the National Health Insurance Bill in 2003 with an aim to provide universal access to healthcare. The law translated into the National Health Insurance Scheme (NHIS), which comprises three health insurance schemes:

• District mutual insurance
• Private mutual insurance
• Private commercial health insurance

Every Ghanaian resident is required to enroll in one of the three schemes under the law.

The paper summarizes the health insurance landscape and underwriting practices in Ghana.

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Medical underwriting and risk adjustment practices: Spain

Health insurance models vary from country to country. As highlighted in our first series of articles on international health markets, governments often dictate the role of private and public health insurance within any country. Milliman has produced a new series of blogs focused on the medical underwriting and risk adjustment practices of eight countries: Australia, Ghana, Ireland, New Zealand, Saudi Arabia, South Africa, Spain, and United Arab Emirates. This is the second article in our series.

The Spanish National Health System (NHS) follows an integrated model in which the financing (through general taxes), purchasing, and provision of health services are mainly public. It offers universal coverage and, in accordance with the Spanish Ministry of Health and Social Policy, 95.8% of the total population was covered in 2011.

Since 2002, the organization of the NHS has been decentralized across the 17 autonomous communities in which the territory is divided. The central government is responsible for ensuring equitable access to health services across the territory and keeps its authority over areas such as regulation of pharmaceutical products.

Patients are required to visit the general practitioner assigned to their specific geographic health areas, who in turn refers patients to corresponding specialists as needed.

In April 2012, a health reform introduced different measures to control the public health expenditure, such as the regulation of the conditions to provide health services to undocumented immigrants and the extension of selective copayments on pharmaceutical products. The copayment is established taking into account the level of income and whether the person is retired or actively working. Copayments are not applied in only a few cases, for example the long-term unemployed and low-income groups.

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Medical underwriting and risk adjustment practices: Australia

Health insurance models vary from country to country. As highlighted in our first series of articles on international health markets, governments often dictate the role of private and public health insurance within any country. Milliman has produced a new series of blogs focused on the medical underwriting and risk adjustment practices of eight countries: Australia, Ghana, Ireland, New Zealand, Saudi Arabia, South Africa, Spain, and United Arab Emirates. This is the first article in our series.

The national public health system in Australia—”Medicare”—provides universal health coverage for all Australian citizens and most permanent residents. It provides free or subsidized access to most medical services and prescription pharmaceuticals. It is largely funded from general taxation, including a statutory insurance levy, which is 1.5% of taxable income (some low-income people are exempt or pay a reduced levy). Individuals and families on higher incomes who do not take out private hospital insurance pay an additional means- tested Medicare levy surcharge of 1%-1.5% of taxable income. The remaining funding comes from private out-of-pocket payments.

The benefits received from Medicare are based on medical and pharmaceutical fee schedules set by the government. Medicare usually pays the full schedule fee for general practitioner (GP) services, 85% of the schedule fee for other outpatient services, and 75% of the schedule fee for inpatient services when treated as a private patient in either a public or private hospital. Services provided to public patients in public hospitals are free of charge. GPs and specialists charge on a fee-for-service basis and can choose to charge more than the fees in the schedule.

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Register for Milliman’s Actuarial & Underwriting Training Seminar

Milliman is hosting an Actuarial and Underwriting Training Program for Blue Cross/Blue Shield plans, health maintenance organizations (HMOs), and insurance companies, scheduled for January 7-10, 2013, at Disney’s BoardWalk Resort in Lake Buena Vista, Florida.

The event will feature distinguished speakers with considerable experience in the topics they will be presenting. Attendees will also have time to engage each instructor during question and answer sessions.

The seminar is intended to be an organized activity as defined by the American Academy of Actuaries Qualifications Standards for Actuaries Issuing Statements of Actuarial Opinion in the United States.

Seats are going fast, so register now!

For more information about the seminar, including a list of presenters, see the brochure. Please contact Christina Carlin via email or at +1 952 820 2480 if you have any additional questions.

Global underwriting: Hong Kong, China, Singapore, and Malaysia

The role of private health insurance differs significantly from one country to another. A key reason for this relates to the availability and the delivery of public healthcare within each country. In addition, governments often dictate the role of private health insurance within any particular country. This eight-part series focuses on international health markets, comparing and contrasting the key elements of risk selection practice in the public and private health insurance markets in each region.

Health insurance market summary
The provision of hospital inpatient care in all of these countries is mostly provided by public hospitals. Conversely, the provision of outpatient primary and specialist care is dominated by the private providers, which is due to the lower cost per visit and convenience (private clinics are spread across the country compared with the limited locations of hospital-based primary and specialist facilities in the public sector). One exception is China, where outpatient care is also mostly provided by the public sector.

In the case of China, the financing of public care is via a social health insurance (SHI) program, while in Hong Kong, Malaysia, and Singapore it is funded by an allocation of government budgets with limited out-of-pocket payments by the patient at the point of service.

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